What to do when a patient tests positive for Human Immunodeficiency Virus (HIV)?

Management of Patients with Positive HIV Test Results

When a patient tests positive for HIV, immediate confirmation with a Western blot or immunofluorescence assay is essential, followed by prompt linkage to comprehensive medical care, psychosocial support services, and counseling about preventing transmission to others.

Confirmation of HIV Diagnosis

1. Confirmatory Testing:
   • Positive screening tests for HIV antibody must be confirmed by a more specific confirmatory test (Western blot or indirect immunofluorescence assay) before being considered definitive 1
   • If acute HIV infection is suspected (fever, malaise, lymphadenopathy, skin rash), perform HIV RNA testing which can detect infection before antibodies develop 1, 2
   • For infants under 15 months born to HIV-positive mothers, diagnosis should be based on laboratory evidence of HIV in blood or tissues by culture, nucleic acid, or antigen detection (not antibody testing alone) 1

Initial Medical Evaluation

1. Baseline Laboratory Assessment:

   • CD4+ T-lymphocyte count and HIV viral load (HIV RNA level) to assess immune status and disease stage 2
   • Complete blood count and blood chemistry profile 1
   • Screening for co-infections:
     • Tuberculosis (TST/PPD skin test)
     • Hepatitis A, B, and C serologies
     • Syphilis serology and other STI testing
     • Toxoplasma antibody test
     • Serum cryptococcal antigen if CD4 count <100/μL 2
   • Resistance testing (baseline genotype) to guide antiretroviral therapy selection 2
   • Chest radiograph 1

2. Physical Examination:

   • Look for signs of opportunistic infections (oral candidiasis, skin lesions)
   • For women, include gynecologic examination with testing for N. gonorrhoeae and C. trachomatis 1

Treatment Initiation

1. Antiretroviral Therapy (ART):

   • Start ART as soon as possible, ideally within 7 days of diagnosis, unless there are contraindications 2
   • Early treatment reduces morbidity, mortality, and risk of HIV transmission 2
   • Regimens typically include multiple antiretroviral medications such as protease inhibitors (like darunavir) 3 or integrase inhibitors (like raltegravir) 4

2. Prophylaxis for Opportunistic Infections:

   • Initiate prophylaxis for Pneumocystis pneumonia, Toxoplasma encephalitis, and other infections based on CD4 count 1

Follow-up Care

1. Monitoring Treatment Response:

   • Assess adherence and medication tolerability within 6 weeks of starting ART 2
   • Measure HIV RNA level at this 6-week visit 2
   • Monitor HIV RNA every 3 months until viral suppression for at least 1 year, then every 6 months 2

2. Immunizations:

   • Offer hepatitis B vaccination to patients without hepatitis B markers 1
   • Provide annual influenza vaccination 1
   • Administer pneumococcal vaccination 1

Psychosocial Support and Counseling

1. Immediate Counseling:

   • Patients who test positive should be counseled by someone able to discuss medical, psychological, and social implications of HIV infection 1
   • Address major adaptive challenges: accepting possible shortened life span, coping with stigma, maintaining health, and preventing transmission 1

2. Behavioral Risk Reduction:

   • Provide assistance in changing behaviors that can transmit HIV to others 1
   • Discuss safe sex practices including consistent condom use 2
   • For injection drug users, discuss needle exchange and harm reduction strategies 1

3. Partner Notification:

   • Encourage disclosure to spouses and sexual partners 1
   • Offer assistance through health department partner notification services 1

Common Pitfalls to Avoid

1. Delayed Linkage to Care:

   • Ensure patients receive their positive test results and are promptly connected to care 1
   • Avoid fragmentation of care by coordinating between providers 1

2. Inadequate Screening for Co-infections:

   • Missing co-infections like hepatitis, tuberculosis, and STIs can lead to poor health outcomes 2

3. Poor Medication Adherence Support:

   • Discuss potential barriers to care (transportation, insurance, housing, stigma) 2
   • Consider technology support for medication adherence (alarms, pill boxes, electronic reminders) 2

4. Overlooking Psychosocial Support:

   • Address mental health, substance use, and social determinants of health 2
   • Ensure appropriate social support resources are available 1

HIV is now a manageable chronic disease with near-normal life expectancy when treated appropriately. The key to successful management is early diagnosis, prompt initiation of effective antiretroviral therapy, comprehensive screening for co-infections, regular monitoring, and addressing both medical and psychosocial aspects of care.